Failure to Implement Abuse Policy for Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy regarding the reporting and investigation of an injury of unknown origin for a resident with multiple sclerosis and non-Alzheimer's dementia, who was rarely or never understood and required maximal assistance for daily activities. The resident developed a significant bruise on her left leg, which was first noticed by her family and reported to nursing staff. The family expressed concern that the bruise resembled handprints, while staff speculated it may have resulted from the Hoyer lift or wheelchair use. Despite the resident's inability to communicate the cause of the injury, the incident was not reported as an injury of unknown origin, and a thorough investigation, including staff interviews, was not conducted as required by facility policy. The Director of Nursing assessed the bruise and implemented a new intervention to prevent further injury but did not document any interviews or follow the established abuse policy for reporting and investigating such incidents. Staff interviews confirmed that the required steps for investigating and reporting the injury were not followed, and some staff were unaware of new interventions put in place. The facility's policy mandates thorough investigation and timely reporting of all alleged violations, including injuries of unknown source, but these procedures were not adhered to in this case.